“Clutching Onto the PrEP Bandwagon, Trying Not to Fall Off”: Experiences of Gay, Bisexual, and Other Men Who Have Sex with Men Accessing and Utilizing Pre-Exposure Prophylaxis (PrEP)

Background and Purpose: Daily use of pre-exposure prophylaxis (PrEP)—combination HIV antiretroviral medications that substantially reduce the risk of HIV acquisition—has been approved in the US and Canada for HIV prevention. PrEP is recommended for sexually-active gay, bisexual, and other MSM (GBM) at risk of HIV acquisition due to behavioural, social, and structural factors. As clinicians and educators, social workers are well-positioned to facilitate PrEP access and uptake among GBM through individual counselling, resource referral, and advocacy. Understanding the experiences of GBM is critical to develop context-specific and community-responsive social work PrEP interventions. To this end, we conducted an exploratory qualitative study to understand the experiences of GBM in accessing and utilizing PrEP.

Methods: We recruited GBM (n=29; 15 PrEP users, 14 non-users) between October 2015 and March 2016. Participants were recruited purposively (ethno-racial identity, PrEP use status) from community-based organizations, HIV/STI and other health clinics, and online (e.g., Facebook). Participants completed in-depth semi-structured 45 to 90 minute interviews that explored access to PrEP (access to information, engagement with the healthcare system), and utilization of PrEP (factors influencing PrEP uptake, adherence, and disclosure). Interviews were audio-recorded, transcribed verbatim, and analyzed independently by two authors using thematic content analysis guided by a grounded theory approach and utilizing a constant comparative method.

Results: Participants described varying degrees of engagement with PrEP: from those on PrEP who identified as “PrEP advocates” and those ambivalent about their PrEP use, to those not on PrEP with a strong desire to be on PrEP, and those not on and opposed to PrEP. PrEP access was facilitated by opportunities to engage with information and receive healthcare from non-judgmental, competent physicians, and constrained by financial cost. PrEP information was readily consumed by both PrEP users and non-users, whose sources included research (academic journals, blogs), talking with others (friends, family, physicians), and online PrEP forums. PrEP users described positive experiences with healthcare (physician competence and support) and most non-users believed they would be comfortable discussing PrEP with their primary physicians. Utilization was characterized by complex decision-making processes, and experiences with adherence and disclosure of PrEP use. Decision-making processes were informed by considerations of PrEP safety (e.g., potential side effects), efficacy, current and anticipated sexual risk practices, and potential benefits (e.g., protection from HIV, and reduced anxiety). Most PrEP users reported high adherence, facilitated by multiple mechanisms (e.g., setting a timer). Participants reported strategic disclosure of their PrEP use to others (e.g., family, friends, sexual partners) with both supportive (e.g., community building) and stigmatizing results (e.g., rejection).

Conclusions and Implications: Findings suggest that social work practitioners may support GBM in considering PrEP through facilitating the assessment of sexual risk practices and anxieties; provision of accurate information about PrEP safety and efficacy; linkage to competent healthcare providers; supporting navigation of PrEP disclosure and coping with negative disclosure experiences; and exploring options for insurance coverage. At a structural-level, social workers can advocate for expanded PrEP coverage. Future research is needed to inform tailored social work interventions in the context of PrEP.